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The Irony of Bangkok

How to Get 6 Million Poor People on Antiretroviral Therapy -- and 1 Million Rich People Off

In a brief July editorial, "Freedom of Choice," UK-based AIDS Treatment Update editor Edwin Bernard captures the essence of the present day therapeutic conundrum. "It's ironic," he writes, "that whilst the main focus of this summer's XV International AIDS Conference in Bangkok was on finding ways to get everyone who needs therapy onto HAART, treatment interruption has become a hot topic in well-resourced countries, as concerns over resistance and side effects are increasingly recognised as issues in managing HIV disease."

Whereas at last summer's IAS conference in Paris, two key week on, week off (WOWO) intermittent treatment studies (the Dutch Staccato study and the NIH's own WOWO trial) led to disappointment, this year there has been renewed interest in the concept of pulsed therapy driven by CD4 cell count measures (cycling on and off ART according to pre-defined CD4 count thresholds), due in part to promising preliminary results from the Italian BASTA trial and publicity surrounding the ongoing SMART trial, which is currently enrolling study volunteers in 22 countries worldwide. There was even an admittedly symbolic renaissance of exploration into induction/maintenance approaches.

The BASTA study has patients go off therapy at a CD4 cell count of 800 and then back on at a threshold of 400. The stop/re-start threshold for SMART (www.smart-trial.org) are lower: off treatment once the CD4 cell count rises above 350; re-start if it falls below 250. Edwin's excellent overview of these two key studies can be found at aidsmap.com (www.aidsmap.com/en/docs/1233FABB-86F6-4AF4-955E-4EB5F149F882.asp).

Cohen CJ, Morris A, Bazner S, et al. The FOTO Study: A pilot study of short-cycle treatment interruption, taking antiretroviral medications for Five days On, Two days Off (FOTO), for those with viral load suppression. Abstract TuPeB4575.